Report The Nursing and Midwifery Council s review visit to the maternity services at Northwest London Hospitals NHS Trust. July 2007.

Transcription

1 Report The Nursing and Midwifery Council s review visit to the maternity services at Northwest London Hospitals NHS Trust July 2007 Page 1 of 22

2 Contents Page The Nursing and Midwifery Council 3 Background to this review 3 Terms of Reference 4 The Review 5 The Environment of Care 6 Service User Experience 8 Leadership, Communications and Team Working 9 Staffing: numbers, skill mix and development 10 Commissioning and recruitment of students 11 Student learning, supervision and support 12 Student assessment 15 Failing students 16 Supervisors of Midwives 16 Conclusions 18 Recommendations 21 Page 2 of 22

3 The Nursing and Midwifery Council The Nursing and Midwifery Council (NMC) regulates two professions, nursing and midwifery. The NMC s primary function is protection of the public and it does this by maintaining a Register of three parts, which relate to Nurses, Midwives and Specialist Community Public Health Nurses. The NMC sets the Rules and Standards of education and practice required by those wishing to join or remain on its Register and by monitoring that those standards are met. The NMC publishes a Code of Conduct that all nurses and midwives must work to. It also sets the standards required of Local Supervising Authorities and Supervisors of Midwives as well as for the approved education providers that train pre-registration nurses and midwives. The NMC is empowered to do this by the Nursing and Midwifery Order 2001 (The Order). Background to this review. In July 2005, an NMC review team made an extraordinary visit to the maternity services of Northwick Park Hospital (NWPH) to investigate the suitability of the learning environment for pre-registration student midwives. The decision to carry out an extraordinary NMC visit was a result of Special Measures being imposed on the maternity services at the Trust by the Secretary of State. This followed two Health Care Commission (HCC) investigations into events and systems failures in the maternity service. The NMC report (December 2005) on this visit is available on the NMC website. The recommendations in this report were approved by the Council of the NMC (appendix 1). In December 2005 the NMC withdrew approval for any new midwifery students to be placed in the maternity service at Northwick Park Hospital. Student nurses also were not to be placed within the maternity services. These conditions apply until such time as the NMC is satisfied that recommendations and action plans had been carried out and that any improvements made are sustainable. This required the NMC to conduct a further review once special measures had been lifted from the unit. In addition the first extraordinary visit identified the key role that Statutory Supervision of Midwives at NWPH needed to play in enhancing student experience of womancentred and evidence-based practice. This resulted in the Council of the NMC requesting a full review of the Local Supervising Authority (LSA) input into the Page 3 of 22

4 situation at NWPH. This took place on 3 rd February 2006, the report of which is also available via the NMC website. The recommendations of this LSA review are provided in appendix 2. Special measures on the NWP maternity unit were not lifted until the summer of 2006 and therefore the NMC return review was deferred until 27th February This report sets out the terms of reference for the review, the information and evidence gathered during the review and the recommendations of the review team to the Midwifery Committee (and then to the Council of the NMC.) Terms of Reference The NMC review team will conduct a second visit to the maternity services of the North West London Hospitals NHS Trust to assure Council that sustainable improvements are in place on its Northwick Park site following removal of special measures in September The NMC will review the suitability of the learning environment for student midwives to assess whether approval of further intakes of student midwives can be given by the NMC. This will include: 1. Is the environment of care within the maternity services woman centred, evidence based and appropriately balanced between normal/abnormal pregnancy and birth? 2. Would student midwives be supported appropriately within the environment at the Trust? 3. Are the LSAMO and supervisors of midwives involved in planning the student midwife intake and do they input into the decision on the number of student midwives taken on? 4. Is midwifery staffing appropriate to provide safe care to women and safe mentoring and supervision of student midwives? Page 4 of 22

5 5. Has there been sustainable improvement in internal communication and team working within the maternity services, such that students would be exposed to good role modelling and good practice? 6. Are midwives using best practice when caring for women and their families and is this taught to students in the unit? 7. Is supervision of midwives improving the learning and caring environment within the Trust? The Review The Head of Midwifery and Gynaecology Colette Mannion, Elizabeth Robb, Director of Nursing and the Chief Executive Mary Wells, welcomed the review team (appendix 3) to Northwick Park Hospital. After initial introductions and presentations from staff the review team split into two groups to meet with staff, students, and lay representatives and to visit the unit itself. The timetable for the visit is detailed in appendix 4. The review team would like to thank those members of NWPH, Thames Valley University (TVU) and the Local Supervising Authority Midwifery Officer (LSAMO) who organised, participated in and supported the visit. In particular the team would like to commend the enthusiasm, commitment and work of all concerned to bring about and sustain the improvements in the maternity service since the team s last visit. The management team was led by Mary Wells, Chief Executive, and the review team commend her support to ensure that NWPH is a safe maternity unit that mothers want to come to for their baby s birth and that students will choose for their midwifery practice placements. The review team would also like to express appreciation and thanks for the facilities, hospitality and time given to meet with us during the visit. Page 5 of 22

6 The Environment of Care The maternity unit has now been completely refurbished and high dependency and post-operative recovery areas established. During the tour of the unit the team found a huge change in the physical environment. It had a more positive and open sense of space, cleanliness, modernity and privacy for women. Posters about violence towards staff had been replaced with positive pictures of mothers, fathers, babies and midwives, which further enhanced a woman-centred and friendly ambience. Seats and tables are provided to encourage women to get out of bed, move around and socialise in the wards. The unit s delivery suite has a birthing pool, however the review team were told by midwives that it had not been used for water births and that it was early days in this regard. It was reported that that the recently appointed consultant midwife was planning to provide training and roll out a water birth programme. Midwives were clear that there had been very little activity with the pool to date although some use of it had been made for pain relief. Although students and midwives said they used birthing aids such as balls none of these were visible during the tour. Statistics to March 2006 (London LSA) indicate that NWPH has a 27% caesarean section rate. The vaginal birth rate of 63% includes 16% planned inductions of labour, and 17% of labours that are accelerated. 10 % of births were instrumental divided between 2% forceps and 8% ventouse extractions. 50% of women using the Trust are classified as being in the high risk category using the Birthrate plus tool (2005). Guidelines have been produced to promote normal birth although the midwives admitted that there is some way to go on the normal birth agenda. However they have made a good start by planning to implement water birth and having birth balls etc. It will be important to ensure that this momentum is maintained as some students reported they had not always seen enough normal births by the end of their training. Students had gained most of their experience at NWPH but they also have the opportunity for a placement at the Brent Birth Centre, which is a midwife led unit. Only about 300 births take place there a year, hence not all students gain experience in supporting women who birth at Brent. The balance between high and low risk pregnancies remains a challenge for midwives at NWPH and a few students Page 6 of 22

7 expressed concern that they still had a considerable number of normal births to undertake in their final six months. Midwives noted that where medical staff used to see every woman present on the labour ward, now they only enter rooms where the woman has a complication or the midwife requests a second opinion. The employment of new midwives and the consultant midwife, students believe, has had a positive impact on keeping birth normal. Students reported seeing more midwives encouraging women to get out of bed, mobilise and use birthing balls. The students reported that midwives are now seen to offer women physiological management of the third stage of labour. There is encouragement for women to have skin-to-skin contact with their babies at birth, a practice that was not seen by students in the past. It was reported that initiation of breastfeeding has improved and a breastfeeding specialist health visitor jointly funded by the Trust and PCT supports women. The review team were informed that to help address the challenges of a multicultural/ethnic catchment area, there has been an improvement in the interpreting services and the range of leaflets printed in different languages. A review is taking place into provision of midwifery in the community and the intention is to have an integrated model of care to include focus on vulnerable women. It was reported that not all midwives are enthusiastic about promoting home births. Evidence based guidelines have been produced, are kept updated and are easily accessible in the clinical areas and on the intranet. In particular these guidelines incorporate recommendations of the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Midwives (RCM). All staff are required to attend a mandatory training programme to keep them updated. This includes emergency procedures and those required by the Clinical Negligence Scheme for Trusts (CNST). A small amount of time (90 minute session) in the five-day programme is allocated for the promotion of normal births and this could be improved further. Overall midwives and students described a transformed unit where staff help each other and there is an open, questioning culture that supports staff and student learning needs. Supervisors of Midwives (SoM) were reported as always visible and the management system was felt to be supporting and nurturing. SoM s reported Page 7 of 22

8 that from feeling that they were climbing a mountain and being knocked down, they now feel good about working at NWPH. Service User Experience The review team met with four women and one partner, who were identified by the Trust. One of the women was there as a representative of the National Childbirth Trust. (NCT) and two were also employees of the Trust. We acknowledge that this group was small and their experiences may not be representative of all women using services at Northwick Park. The women who had birthed recently found the environment of their room to be good, birthing balls were available, and that they had received one-to-one care and their questions were answered. They felt there was a team approach to care. Care was tailored to individual needs and a very high level of postnatal support had been given in response to complex medical needs. On the whole, these service users were very positive about their experience of care at Northwick Park. One woman said that she was sorry she did not have a student with her as the student could have provided continuous support through labour. The implication of this is that some women may not be receiving continuous support during labour. The NCT representative reported they had received a number of complaints that fathers were sent home while their partners were in early labour and/or following induction and that the women involved found it distressing to labour without their partner. Those who had given birth recently reported better breastfeeding support than those who gave birth some time ago. Page 8 of 22

9 Leadership, Communications and Team Working Management reported that the external support they received following the instigation of special measures was extremely helpful for their Trust. The Clinical Director has been in post for just over three years and had taken the initiative to write to the Healthcare Commission. It was reported that team building and good communication have been key strategies in bringing about improvements. The Chief Executive (CE) chairs the Trust s internal Maternity Action Planning meeting, although it is unclear whether this will continue when she retires. The Director of Nursing (DN) is continuing in post and is supportive of all the processes that have been put in place in the maternity services. There is a requirement at every public Board meeting for there to be a report on progress of the maternity services. A clinical risk midwife has been appointed and a multi-disciplinary labour ward forum established since These forums provide the opportunity to review all labours that have taken place over the last 24 hours. Risk management, audit, practice guidelines and clinical governance meetings are open to all staff. The need to develop clinical leadership has culminated in a Trust wide programme accredited by TVU. Modern Matrons have been recruited and they were charged with developing quality measurements in relation to for example: normal births, water births, physiological third stage of labour, home birth rates, induction rates, vaginal birth after caesarean section and caesarean rates. The review team were not shown any quality measurement tool during the review. Individual interviews were held with the Head of Midwifery (HOM), modern matrons and the acting clinical risk midwife. These managers said they have sufficient staff to provide one-to-one care in labour and for mentors to provide students with the time needed to support their learning and assessment. The former poor relationships between theatre nurses and midwives have been addressed by employing the nurses specifically to work in the maternity theatres so that they are part of the maternity services team. Page 9 of 22

10 Staffing: numbers, skill mix and development Part of the past difficulties for the Trust had been attributed to poor midwifery staffing levels. This has now been remedied with 20 additional posts which were funded immediately. The review team have also been informed that there is an agreement to appoint a further 20 midwives within the subsequent two years of which 5.4 posts were agreed in December Currently the number of births planned for the unit are 4850 pa with an expectation that this will increase to 5000, including the birth centre. At the time of this review the staffing levels (excluding medical staff) comprise: Consultant midwife 1 (50% of time is in clinical practice) Midwives 164 WTE (17% vacancy rate which it is anticipated will be filled shortly) Midwife: birth ratio is 1:30 Theatre/recovery nurses 13.4 WTE Maternity assistants 32.2 WTE Consultant medical staff comprise: Obstetrics (O) only 4 Gynaecology (G) only 4 O & G 4 Students reported that maternity assistants working on the labour ward start off the admission process, do the woman s observations, help her to shower, attach the Cardio Toco Graph (CTG) monitor, do the meals etc. These reports, although not triangulated with review of the admission process, are concerning. Should this be the case then inappropriate delegation may be taking place. Maternity support staff do not have the knowledge or skills to assess whether a woman is in labour or how to perform and interpret the abdominal palpation required to enable accurate attachment of a CTG monitor. Similarly they do not have the knowledge to assess whether a CTG is required at all or interpret the readings from the CTG. There has been recognition of the importance of staff maintaining and updating their knowledge and competence and to this end there is now a requirement that all midwives attend an annual five-day mandatory programme of which a number of sessions are designed for multi-professional attendance. In addition mentors are Page 10 of 22

11 required to attend an annual mentor updating session, which they reported as very useful. The local supervising authority (LSA) has an active database that is used to record mandatory training, appraisal and annual SoM review. This is a web-based database and is accessible from within the Trust. Although the team did not meet with any newly qualified midwives, students commented that new staff had told them they felt confident after three months because of the support they had received. The Clinical Practice Facilitator (CPF) post was funded by the SHA for 3 years and this has been extended for a further year. However there is uncertainty about its sustainability after the end of A number of respondents mentioned a lecturer/practitioner post that was seen as key in instigating the staff development programme but reported that this post has been cut. Commissioning and recruitment of students All those interviewed supported the decision of the NMC, following the extraordinary visit in 2005, to allow current students to complete their programmes at NWP, but to suspend any further intakes of new students until there was evidence of sustained improvement following the lifting of special measures. Staff reported they found the smaller number of students had given them the space to review their practice and to concentrate on their own development needs. However there was a strong commitment from everyone at all meetings for the return of new intakes of student midwives. It was reported to the review team that meetings had been held to determine an appropriate intake of students from the 2007/2008 academic year should approval be reinstated. Those involved in these discussions included: 8 10 Supervisors of Midwives, the Lead Midwife for Education from TVU, and the link lecturers. A conservative approach was considered to be prudent, given the work that needed to be done to prepare enough mentors to meet the NMC standards, the time that had elapsed since they had facilitated the learning of 1 st year students and the relatively large number of recently qualified midwives who needed preceptors. (About 40% of midwifery staff) The following commissions therefore were recommended by NWPH and TVU: Page 11 of 22

12 September 2007: October 2007: 4 Pre-registration eighteen-month programme student midwives 4 Pre-registration three-year programme student midwives Assuming annual intakes subsequently, this will give a maximum number of students at any one time of 20. This compares with the 40 student midwives commissioned per annum that were allocated to NWPH before the instigation of special measures. Student learning, supervision and support There are 12 student midwives remaining at NWPH of whom the review team met 9. These students are due to complete their three-year programmes this year and reported they were keen to seek employment with the Trust. The Trust is equally keen to employ them. A steering group was set up to support the learning and retention of existing students following the NMC extraordinary visit. Most of these students have now graduated and are working at NWPH. In order to ensure that student nurses meet the EU requirements, alternative learning activities have been implemented that do not require students to have a practice placement in the maternity unit at NWPH. It was reported by TVU staff, that if a student nurse demonstrated an intention to pursue a career in midwifery, placement experiences would be negotiated on an individual basis, though this is contrary to the recommendations in the first NMC report. The review team were told that the mentorship programme has been developed to equip mentors in their support of students and a CPF has been appointed whose key role is student support. Work is in progress via TVU to address the new NMC standards for mentorship. In addition 2.5 link tutors were allocated to NWPH from TVU. It s not clear whether this level of support will be sustained by TVU or whether there is a strategy to determine the tutor resource according to the number of students. It was reported that approx 60% of midwives have been prepared as mentors. The remaining 40% of the midwifery workforce are either newly qualified or have not Page 12 of 22

13 undergone a mentor preparation programme, and therefore do not meet NMC requirements to mentor students. The nine student midwives who met with members of the review team stated unanimously, that they were enjoying their course and were pleased that they had been enabled to remain at NWPH. They reported an immense change in the quality of mentorship and felt that they are now very well supported, have better continuity of mentor and at times feel that as students they are on a pedestal. They felt the focus is on student learning needs and how the mentor can facilitate them to achieve the required experiences. Students were clear that they are supernumerary and the increase in responsibility they have been given recently is to fulfil their learning needs as a senior student, not to compensate for staff shortfalls. Students described finding the culture of the hospital to be much more conducive to learning as there is good communication between staff that work as a team and hence students feel they can approach anyone with questions. They informed the reviewers that routine admission CTGs did not take place anymore. This view may conflict with their description of the role of the maternity assistant in admitting women to the labour ward and commencing CTGs. They reported feeling confident to question the rationale should they witness routine CTG tracing now. Students reported that when they are involved in critical incidents, midwives ensure that students are de-briefed about it which was not what happened two and a half years ago. In particular the bereavement midwife was described as excellent. It was stated that maternity support workers also contribute to student learning. This was described as helping students to learn skills such as baby bathing and reorientating students to a placement, because the support staff remain in an area for a long time. In relation to interprofessional learning it was reported that students have been included in meetings to plan care for women and families with complex needs. The professions involved in this joint decision making include paediatricians, midwives and social workers. In addition students attend the delivery suite day after reviews of care that are open to all relevant professions. From their observations students found everyone was able to make a contribution to the discussion and felt that all opinions were valued. Page 13 of 22

14 More recent initiatives to enhance the student experience include student forums and group sessions with a Supervisor of Midwives. Link tutors and Supervisors of Midwives attend these meetings as well as the Clinical Practice Facilitator (CPF) who is also a Supervisor of Midwives. Students reported that they found the CPF invaluable; she does their allocations and will also work with them clinically. The link tutors are on-site on Wednesdays but can also be contacted by if necessary. Individual interviews were held with six mentors. All had found it a positive move to reduce the number of students as at times they had felt inundated with students yet were receiving very little support themselves. The mentors also commented that students need the right environment to learn well and two years ago morale and staffing levels were very low. These mentors felt that it is the right time to commission new intakes of students, as the mentors find them stimulating and learning becomes a two-way process Opinions were expressed that they must be able to maintain the support they are giving to the current students when they start to increase student numbers. Mentors also valued the role of the CPF in relation to student needs and concerns. Their view concurred with that of the students that the CPF is responsible for the allocation of students to mentors when on hospital placements. Mentors reported that they now find it easy to contact the link tutors as they regularly attend NWPH. Managers do not act as mentors to students but do on occasions work with them. They believe the students gain a positive learning experience in all areas at NWPH however not all managers receive student placement evaluations. At present the three link tutors do not have the opportunity for much hands-on midwifery practice but reported that TVU is supportive in enabling them to maintain their skills and that they can opt for a week out from the university to spend time in clinical practice. They regularly attend NWPH on Wednesdays, which includes an invitation to the practice guidelines group and the labour ward forum. Communication between the link tutors and NWPH staff was described as good. If students need to communicate with tutors at other times, they generally do so by e- mail. Page 14 of 22

15 Student assessment At the time of the extraordinary visit in 2005, students found it stressful to get their practice book signed. They reported that now they have more proactive mentors with whom they work for three shifts a week; they felt that mentors are more confident to sign them off. Because the CPF allocates the mentors they assume s/he has fulfilled the requirements to be a named mentor and they know that only a mentor can sign off their practice book. Students did however note there were differences in mentors preparedness to sign them off. Students explained that there were different practice assessment methods. They reported that they self assess whether they have achieved a number of skills as well as keep a record of the number of activities they experience to fulfil the EU requirements. They described a different assessment book that has to be signed off by the mentor and which is specific to a practice area, and does not follow from one area to another. The students informed the reviewers that they choose objectives to meet the learning outcomes for each placement and the mentor they work with on that placement is required to determine whether they have achieved those objectives or not. Mentors agreed that there is a new booklet for each placement. The practice assessment tool has discreet elements to it and the student s skills book is a separate document from the mentor assessment of specific objectives. Students stated that they self assessed as to their competence in these skills and signed themselves off in the skills book. Mentors said that they could ask to see any of the student s practice books if they had concerns about aspects that they were not required to assess on the current placement. This matter was explored further with the LME. From what the review team were told their understanding was that issues around the assessment tool had been raised in an NMC Quality Assurance monitoring visit that took place during the previous year. The review team s understanding was that these issues had been addressed and new documentation would be ready for implementation for any student intake in September 2007, Page 15 of 22

16 Failing students Students were asked what would happen if a mentor had concerns about their capability. Whilst the students were not aware of this having happened, they were clear that the mentor should discuss it with the student concerned and then refer their concerns to the CPF and the link tutor. Students said that if they did not agree with their mentor s judgement they would ask to work with the CPF to show they could achieve the objective(s). The mentors gave a similar explanation of the process that would be followed if they had concerns about a student s performance. They were quite clear about their accountability to protect women from unsafe practitioners and this could mean referring their concerns about a student to the link tutor. The CPF believed that mentors would come to her if they had problems with an individual student. In the past mentors have not alerted her to these problems until quite late but now, through the initial and midway interviews with students, she believes problems will be identified much earlier. Supervisors of Midwives from Northwick Park reported they were not involved in TVU Board of Examiners and therefore they are reliant on the link tutors and can only assume that their concerns are upheld. Link tutors believe they still have more work to do in supporting mentors when they have to make difficult decisions in assessing students. They have started to implement a tripartite system. This involves a joint assessment by three people, the student, the mentor and the tutor. Although is has been found to be very useful in the assessment process it is very time consuming and difficult to co-ordinate with mentor/student shifts. However, tutors believe an incompetent student would not be able to pass. This was because they know the students well and talk to the students, as well as going through their skills book with them and discussing student progress with mentors. Supervisors of Midwives The LSAMO presented the Supervisors of midwives (SoM) action plans in response to the NMC recommendations to the review team. This included the view that a key development at NWPH had been the dramatic culture shift. There was now evidence of staff working collaboratively both within and across disciplines. Care is also now focused on the woman s needs and the consultant midwife is charged with promoting Page 16 of 22

17 normality in labour. A community project was also reported to be in progress is based around the organisation of care. The LSAMO has used the balanced scorecard developed by the Trust and agreed by the SHA convened maternity monitoring meeting to look at staffing ratios, a copy of which is included in appendix 5. The ratio of SoM to midwives has improved and is now 1:15 and more midwives have been identified to undertake the preparation of Supervisors course. SoM are now producing reports analysing trends, the investigation of incidents and have reviewed all clinical guidelines. In addition work has been undertaken across London to develop a portfolio approach to benchmarking themselves against standards. It was confirmed that SoM are involved in curriculum development and interprofessional working. They meet with students regularly through group supervision and they advise students how they can access the on-call SoM. None of the link teachers have considered becoming a SoM. The review team held interviews with six SoM. The SoMs explained that they spend time giving support to mentors and newly qualified midwives in particular. Through engaging in dialogue with mentors they identify students who are not achieving and assist them in articulating the reasons for this. SoM have additional areas of responsibility, for example a SoM is the link with TVU, and others attend the labour ward forum, risk management forum, guidelines group, parent partnership group. SoM are involved in carrying out investigations where there is a serious allegation involving a midwife. It was reported that there is a flow chart to show the process when an incident is reported although the review team did not see this. Page 17 of 22

18 Conclusions The NMC commends the work under taken by the management team, supervisors of midwives and staff in transforming the physical environment and culture of NWPH. In particular the leadership and commitment of the Chief Executive, Mary Wells, impressed the team. She will however, have retired by the time this report is published. Continuity will continue through the Director of Nursing, Clinical Director, Head of Midwifery and the supervisors of midwives. All will work in partnership to ensure that improvements are maintained, and the excellent support they provide for current students will be built on and sustained for new cohorts. The changes that have been most important have been: the refurbishment of the hospital and enhancing women s childbirth experiences, increasing the staffing establishment, clinical leadership and team building, governance and education and training of staff. The physical environment at NWPH has seen a dramatic improvement. The refurbishment programme has now been completed and there have been good changes towards a positive and friendly environment for women and their families. Good progress has been made in relation to providing a woman-centred maternity service but staff in the unit realise they have more work to do in addressing the needs of vulnerable groups in a more holistic way and in the promotion of normality in childbirth. The appointment of a Consultant Midwife and the project being undertaken in the community are seen as key initiatives to help address these issues. The Supervisors of Midwives and LSAMO have been proactive in training more SoM so that they can provide more support for midwives and student midwives and help lead the changes in promoting woman-centred care. They are more involved in the governance and risk management of this Trust than was the case in the past. To date however, SoMs from Northwick Park are not involved in TVU Board of Examiners and can only assume that any concerns they have about a student are upheld through communication via the link tutor. Maternity support workers are valuable members of the maternity team who offer support to clinical staff and women by taking on non-clinical tasks that enable Page 18 of 22

19 midwives and obstetricians to focus their time on providing clinical care to women and their babies. The reports relating to use of maternity assistants in the unit may indicate that there is inappropriate delegation of midwifery care to staff that do not have sufficient knowledge or skills to carry out such care. The role of support staff in teaching students is at best limited and at worst reduces the opportunity for students to learn about good and safe midwifery practice from a qualified and registered midwife. SoMs in the Trust should review this situation as an urgent matter and advise management and the LSAMO. If this proves to be the case then it is of concern from a safety for women perspective as well as being inappropriate in the teaching and learning opportunities for students with regard to safe practice. TVU should also review this situation as a matter of urgency. The increase in staffing and reduction in numbers of students has enabled staff to update their knowledge and competence through attendance at an annual mandatory development programme. This has also enabled staff to provide preceptorship support for new midwives and to prioritise student midwives learning needs by the student s named mentor. The review team found that excellent support is being provided for existing students and that strategies are in place to prepare mentors to meet the new NMC standards in time for September Mentors, managers, SoM and tutors are agreed that the decision to halt new intakes of students was appropriate and were consistent that they felt the time is right to plan for new students in the autumn. The number of students proposed (4 eighteen months and 4 three year programme students per year) had been agreed by all key local stakeholders as an acceptable number to guarantee appropriate learning support and the acquisition of the full range of midwifery practice experiences. The present students are all in their third year, are well known to staff and have excellent support from the group sessions with SoM, the CPF and link tutors. It is unclear whether this level of support for students and mentors will be sustained by TVU. Identifying failing students is very much dependent upon the good communications that currently exist between mentors, students, CPF and tutors involved at NWPH and is not enhanced by the current assessment tools. Page 19 of 22

20 Although not within the original terms of reference for this review, information provided during this event requires consideration of the wider context of how a student is assessed for clinical competence. Reports from students indicate that there may be a lack of robust continuous assessment of a student s development and competence through the education provider. The LME reported that the NMC Quality Assurance monitoring visit last year raised some concerns about the documentation used by TVU. Because these matters have come to light and as this assessment tool is being used in other clinical placement settings, it requires further urgent review by the QA framework to ensure that a robust system of assessment of competence in clinical practice is in place for any new intake of student midwives. The review team supports the view that the maternity service at NWPH is capable of accepting limited numbers of new student midwife commissions and wishes to acknowledge and commend the hard work and improvements that the staff there have achieved. The NMC will need to monitor whether any revised assessment documentation along with the tripartite process has addressed the weaknesses identified during NMC monitoring and during this review. Monitoring should also take into account whether mentors have been prepared to the new NMC standards and whether the link teacher resource has been maintained and how SoM support for students is organised when cohorts are at different stages in their programme. Page 20 of 22

21 Recommendations NWPH 1. NWPH must continue to seek to increase the balance of normal/complex pregnancy and birth that all student midwives experience, and how well they are involved in interprofessional learning and teamwork. 2. NWPH must ensure that midwifery care is not being delegated to inappropriate staff. 3. The maternity service at NWPH is ready to recommence provision of clinical practice placement for limited numbers of student midwives. TVU 1. TVU may commence annual intakes of 4 pre-registration (3 year) and 4 preregistration (18 month) midwifery students per year from the 2007/2008 academic year for placement in the North London Hospital Trust maternity services. 2. There should be no increase in the numbers of student midwives at NWPH per year until the first cohort of three-year programme students has completed. The Trust/education provider will have to prepare a case to justify any increase in student numbers in terms of support for students and mentors and the availability of the full scope of midwifery experience. This will have to be approved by the NMC. 3. TVU should not place student nurses to undertake practice placements in the maternity services. 4. TVU must review the input of support workers to the teaching and learning opportunities of student midwives with regard to safe practice. NMC 1. The NMC should review midwifery education provided by TVU so it can be assured that a robust assessment process is in place for the new intakes of student midwives being recruited from the September and October The NMC review of midwifery education provided by TVU should include a focus on Page 21 of 22

22 a. Whether the assessment process and tools are robust, follows the student from one clinical placement to another and assesses all the NMC standards of proficiency for student midwives. b. Validation of how competence is being assessed in practice LSA 1. Supervisors of midwives must review the delegation of midwifery care to support staff to ensure that safety for women using the maternity services is maximised. 2. Supervisors of midwives should consider how they would provide support for student midwives of all cohorts and stages of training. Page 22 of 22